I want to tell you how I came to write the book called The Paper Office. I want to tell this story because it is of both ethical and personal importance to most clinicians.

Twenty three years ago I treated a woman for marital and personal unhappiness with some success. Eight months afterwards she filed a complaint against me with the state Licensing Board. No, I did not sleep with her. Essentially, she accused me of two things: confusing the social and therapeutic roles, and of ‘referring’ her to another psychologist to have a sexual relationship. The resolving of this took almost 4 years.

The Board and I finally agreed that I would have a year of supervision. I must thank Dr. Connie Fischer; she rescued me. Her confidence in me and respect for what I could offer clients and the field carried me through those very difficult times when I simply wanted to quit. With her guidance I came to understand my errors, what the current views of ethical practice involved, and that I could go on.

Okay, what can you learn from my experiences? I think, six things.

1. Just because you intend to do good, do not sleep with your clients, and don’t lie on your billing, these do not guarantee that you are practicing ethically. Look up the definition of tragedy in Greek drama for a better understanding of this issue. Clues: ‘tragic flaw’ and hubris.
2. Things change in the psychotheapy business so keep current. You won’t even know how they have changed unless you make an effort to read what makes you uncomfortable and attend what you shy away from. Keep up to date on ethical issues, concepts and terms, and frameworks for discussions.
3. Do thorough work. Get old records. Get a good history and make all the diagnoses. If I had done those I would have found the pattern of behavior and the diagnosis that led to this critical incident and handled it much better. Be aware that harms that can grow from small errors in decision making, small lapses of judgement, and unexamined assumptions.
4. You can save your own life. However, you may not be able to save your life by yourself. Having peers or friends who care is usually necessary.
5. You too can often make lemonade out of lemons. I had become far too complacent and believed my peers were as well. I had transgressed, but with my supervisor’s care, I grew as well and saw the need to help others learn to play by the newer and better rules to benefit themselves and their clients. My peers didn’t buy and study books on ethics. We attended ethics courses only after they became required. How could I get my friends and peers to do what they must? Finally, I hit on a way: Build the ethics into the clinicians’ ordinary paperwork. Thus the book, The Paper Office. Offer forms and guidelines, summaries and procedures.

Lastly,

6. We all hear about colleagues who violated some rule. We hear usually by rumor, rather sensationalized, and without all the facts and specifics. Please do two things:

• At least, do not pass on this gossip. How would you like to be in his or her place? The colleague has no defense against the unacknowledged.
• If you can, call the colleague and ask what happened. Get the other side. Get the facts. Remember that in America, a complaint is not guilt. Go back to those who told you and tell them what you learned. If you feel justified, offer to help or offer your help to the other side (the Licensing Board, the lawyer, the client, etc.).

The Future of Psychology 1

1. What Business are You In?

• Why are almost all the watches now made in Japan instead of Switzerland?
• Why do railroads only carry bulk like coal and wheat and not packages and people?
• What happened to the local hardware store or travel agency?

These are partly the result of a process Max Weber, the 19th century sociologist, named ‘rationalization’ - the streamlining and increased efficiency of any business over time through improved processes. It is seen in the replacement of small businesses (‘mom and pop’ stores) such as hardware with ‘big box’ retailers such as Home Depot or the replacement of neighborhood luncheonettes and sandwich shops with McDonald’s and other chains and franchises.

But were the experienced Swiss so much less efficient than the startup Japanese watchmakers? The rationalization explanation fails here. Being a RET psychologist I ask, “What is the mistaken belief that led to the shrinkage of Swiss watchmakers, railroad delivery service, and travel agents?” Perhaps the Swiss defined themselves as ‘watchmakers’ and strove to increase their watches’ accuracy while reducing the costs of manufacturing the escapement mechanisms. This is exactly Weber’s ‘rationalization’ concept and does not explain their near demise. But what if they had defined themselves instead as ‘timekeepers?’ They might have noticed that an incidental part of a chip had been developed to sequence the order of a program’s instructions and so kept accurate time to milliseconds. They might have considered how this might be used in watches and so held onto the 90% share of watch production they lost.

In a similar fashion, railroads were improving their ‘railroading’ when their non-bulk, package shipping (remember ‘Railroad Express?’) was taken away by UPS? Then when UPS did not attend the messengering (overnight package delivery) business the upstart Fed-Ex ‘ate their lunch.’ About half the pickup trucks on the road have a ‘cap’ over the bed which allows dry and safe hauling and storage. Who makes them? Leer.

Apparently GM, Ford, Dodge were too busy doing ‘truck making’ to see this need. What happened to all the brands we knew? Why didn’t psychologists develop the amazingly popular ‘codependency’ model of addictions? They did not see what business they should have been ‘in.’

The same is happening to psychologists in the traditional talk psychotherapy business. It is being strangled by meds, genetics, managed ‘care,’ indistinguished competitors, and ‘no insurance.’ Psychology is certainly not just psychotherapy but let us look to that part because it is a service business.

Rationalization and technology led to the replacement of service businesses like travel agencies, purchasing agents, and stock brokers with the internet. (“Anyone who makes his or her living picking up a phone is replaceable by the internet.” Somebody’s Law.) Technology and the profit motive in health care have lead to many changes in how therapy is offered and can be done. If you do psychotherapy you need to ask yourself, “What business am I in?” and consider the implications or you may disappear.
Implications

‘I do therapy.’ Now people will only come to you after they have decided that they have a painful problem, it is the kind of problem that can be helped by therapy as they understand it, they find you, believe that you are a therapist who might help them, and that they hurt enough to take on the burdens of therapy as they understand it (call and come in, pay for, find the time for appointments, etc). Those steps present too high a threshold for many people who would otherwise benefit from your resources.

A simple step to lowering that threshold and getting more business is to shift your focus from services (input, you) to benefits (output, them). You may provide therapy but you also calm fears, improve communication, and strengthen self-control and it is those benefits that clients identify with. Present your business in those terms in your public announcements and potential clients will have fewer steps to take to your office.

A second step is to ask yourself, What business am I in? Gregory House, MD said that physicians do not treat patients, they treat illnesses (episode ‘Paternity,’ season 1). We can be smarter than he if we decide we treat both. Hippocrates noted that “It is better to know the patient who has the disease than it is to know the disease the patient has” and today we can try to know both. (The curious can Google “narrative medicine.”). What definitions of your business does your understanding of the person/disorder or mind/body or society/individual lead you to consider?

Defining Your Work

• Are you a healer such as a curandera (an older female healer who practices Mexican-Indian system of curandismo, santeria or espiritismo) or a similar model in the majority culture here such as a guide, life coach, or personal consultant?
• A ‘poet’ reconsidering emotion in quieter moments of reflection and exploring these with the client?
• An editor helping a new ‘illness narrative’ emerge from the client?
• A Platonic farmer who can see the harvest in the seed and so can help to shape the growth of a person through nurturance/husbandry?
• An archeologist uncovering the past?
• A mirror reflecting and emphasizing what your are told?
• A scientist testing and modifying relationships between events, interpretations, actions and feelings?
• A Socratic ‘midwife of ideas’ aiding the entry into the world of the developed but unrecognized?
• A teacher/trainer of adaptive skills, problem-solving, self-management, etc.?
• An allopathic agent provocateur stimulating weakened resources like the sand does to the oyster to yield a pearl?
• A therapist who treats individual disorder/illness with psychological knowledge obtained scientifically from groups of individuals?
• A family therapist seeking to alter patterns of interaction among members?
• A consultant who works collaboratively and shares specialized knowledge?
• A counselor who offers advice and wisdom?
• All or none of the above?

Your survival will depend in good part on your self-definition of your business.

The Future of Psychology 2

Technology and Psychotherapy

“Ed, I am a therapist and I use technology: I have a computer, several phones, a fax, and a copier. I use a pocket recorder and the Internet.

Do you use any of it when doing therapy?”

No, and with good reason: therapy is more art than science/techniques. As you know, the outcome depends much more on the relationship than the technique.

“Can’t technology enhance the relationship aspects you value so highly?”

Well, I sometimes talk with patients by phone but one needs more information than the voice alone conveys to do therapy. Typing into a Chat program is even less informative. So I do all I can.

I think that is where most of us are but it is not all one can do or where the rest of our society is going.

Technology and Relationships

Lambert (1992) discovered that the outcome of therapy is only 15% due to technique and twice as much due to the relationship. This behooves us to explore how our ways of relating to clients can be improved with technology. Before exploring this an aside: It seems to me that acting classes would be very appropriate for therapists. Perhaps those academicians in ‘communication’ can teach us as well (http://www.colorado.edu/communication/meta-discourses/index.htm)

If we are therapy artists, how do other artists use technological change? Does the ceramicist eschew the electrically powered wheel, pug mill, or kiln because they are not what has been used previously? Does the painter refuse acrylic paint because it does not look like the old oil colors? Does the woodworker avoid the biscuit jointer, always use rubbed oil finishes and never polyurethane, and stick with glues made from horse’s hooves? Do they believe that their art cannot survive with these technologies? Of course not; they adopt improvements and adapt to inventions.

Some Examples of Technology to Expand Relationships

• Automated telephone systems for patients to call in with feedback: daily check-ins for progress and problems with homework, side- and main effects of medications, new insights or needs? Automated callers for prompting behaviors.
• ‘Bug-in-the-ear’ for talking clients through anxiety arousing situations, practicing in vivo desensitization, and other forms of coaching. Bluetooth does this very easily.
• A website for each child patient with “Joey’s News” circulated to all family, teachers, therapists, pediatricians, CYS, the court system, Family Based and Wraparound service workers, and anyone else involved. Everyone can read and comment and everyone knows where they are and what to do. All can identify problems and are sources of solutions. Coordination is much easier and more productive.
• Using computer drawing and art programs for ‘art therapy’ especially with kids (e.g. Kid Pix). There are programs to support play-writing (for family therapy or evoking history?), collecting and organizing scattered ideas (for the histrionic or concentration deficient?), and suite or office programs that allow creative integration of images (graphs, photos, video) with print (timelines, diary, readings) and the variety of materials from the net to articulate or explore an experience or story.
• Teaching parents to use a simple metal clicker to train their pet dog most efficiently and painlessly. Then having the parent use these methods on their children. It works well and reduces both animal and child abuse. <www.latham.org/Issues/LL05wi.pdf>
• Because loneliness is an element of much human unhappiness the internet can skip over the barriers to relationships such as distance, time, appearance/’beautyism,’ and most physical limitations. Shared interests become the only reasons to relate and so the explosion of sites like Facebook.
• ‘Support groups’ for professionals can provide information and sharing. The PPA Listserve provides referrals, answers to questions about practice, ethics, resources for clients and for psychologists, and camaraderie.
• The use of virtual reality for in vitro exposure to otherwise difficult to work with situations such as fears of falling or using public lavatories.
• Collaborating with the client to make use of virtual relationships such as in the Sims series to practice social skills.

References

Lambert, M.J. (1992). Implications of Outcome Research for Psychotherapy Integration, in Norcross, J.C. and M.R. Goldstein, eds. (1992) Handbook of Psychotherapy Integration. New York: Basic Books. pp. 94-129. Lambert’s estimate that therapeutic change is around 40% due to client and extratherapeutic variables, 30% due to relationship factors, 15% due to expectancy and hope factors, and 15% due to the techniques and models of individual approaches.

For more on these ‘common factors’ see Hubble, M.; B.L. Duncan and S.D. Miller, eds. (1999) The Heart & Soul of Change: What Works in Therapy. Washington, D.C.: American Psychological Association.

The Future of Psychology 3

How to Kill a Terrific Profession: Lessons Learned from the History of the Moribund Professional Practice of Clinical Psychology

Born Dying

• Choose a role model for all the professionals that only a few well-supported geniuses have achieved - the Boulder Model.
• Adopt a model that locates the source of interpersonal difficulties inside the person, historically caused, and affecting all of the person’s behavior. As Aaron Beck would note this is a set up for depression: internal, unchangeable, and universal.
• Aspire to a model of completely autonomous practice inappropriate to the subject matter of the profession. One which does not respect the interconnectedness of human problems, is unable to address complex and systemic problems, and is rarely used by other human service professions or in other countries. For example, treatment teams, hospitals, rehabilitation.
• Copy a model of independent practice without providing the survival education for its business aspects.
• Adopt a model from a profession which is itself confused (psychiatry is either a medical sub-specialty or an exploratory endeavor), disappearing (failing to attract the best educated and shrinking in numbers), and uses lesser levels of training (medication is the only treatment).
• Decry the value of technology for the extension and improvement of practice when everyone else is using technology and being creative with it.
• Become distracted by the snazzy new ‘techniques’ of therapy and ignore where the real leverage for change is located - the relationship - because is is harder to measure and train for.

False Idols

• Adopt a diagnostic system which is inherently unreliable and so must be invalid. Fail to develop a better one despite the ability to do so.
• Add an educational burden, without evidence to support its extent, so that a member can prescribe medications whose value is frequently exaggerated by shabby research.
• Encourage a model of self-less service which conflicts with the private practice model and the current models of payment for service, deny the necessity of supporting ‘guild issues’ and hope that others will look out for one’s best interests.

Overpopulation

• Fail to control supply by limiting the training of practitioners.
• Fail to prevent, remodel, remove, or redeploy inappropriate practitioners (not just the criminal or unethical).

Suicide

• Limit the geographic mobility of practitioners so the field cannot adapt to changes and grow.
• Require Continuing Education (because other professions do) without evidence of its value to psychological practice or patients and then allow any kind of activity to be offered as CE.
• Fail to require consultation, support, and mentoring which would monitor and increase the ability of members.
• Abandon methods of demonstrated effectiveness (behavioral modification) because of opposition by the irrational and ignorant.
• Allow your national professional organization to put its needs ahead of its members, staff it with non-practitioners, non-teachers, lawyers, and temporary leaders but not with a cadre of professional managers and experts.
• Fail to assure consistency and quality by standardizing core training so every member is qualified to practice and so is trustworthy to the public.
• Fail to confront and extinguish, or at least submerge, criticism of peers by peers which is pejorative, stereotyped, and arrogant.
• Encourage one’s children to go into other professions.

Arrogance

• Develop a Code of Ethics that is paternalistic, over-detailed, and easily misunderstood.
• Demand levels of payment based on input (education, sacrifice) and not output.
• Fail to employ the skills of other professionals (“I have a doctorate which proves that I can learn to do and be competent in anything”) and trust too much in your own inventions.
• Fail to attend to and learn from the history of other professions.

Dismemberment

• Allow others to perform the functions of one’s profession without the same levels of performance or conformance to ethical rules.

Retreat

• Fail to energetically demonstrate the value of the elements of “psychological mindedness” such as the limitations of memory, that perception and concepts are not isomorphic with reality, and that cognitions create emotions and behavior.
• Fail to unassailably demonstrate the superiority of your profession over others who claim to perform the same function and then to make this evidence universally known.
• Do not energetically use all legal means to prevent competitors from performing your functions.

Starvation

• Fail to arrange funding so practitioners enter their careers with un-payable debts and have to either live as ascetics, take on too much work, or leave the profession.
• Allow your payers to strangle your most useful, practical, and valid activity - assessment.
• Allow those without any expertise in your field but simply pay your bills to dictate your treatments.
• Become dependent on external, competitive financing and allow competition to drive down your income.
• Fail to require the level of funding for professional organizations by members which is needed for growth and stability of the profession.

Gluttony

• Encourage professionals to treat everyone who walks in the door because therapy has few negative effects, you know you can do some good, and the money is nice.